The Danish Twin Study established that only about 20 percent of howlong the average person lives is dictated by genes, while about 80 percent isinfluenced by lifestyle and environment, said keynote speaker, Dan Buettner,founder of the concept of Blue Zones®.1 To better understand the role of lifestyleand environment, Buettner set out to “reverse engineer longevity.”In association with National Geographic and with funding fromthe National Institute on Aging, Buettner and a team of demographers studiedcensus data and identified five pockets where people are living verifiablylonger lives by a number of measurements (Ikaria, Greece; Loma Linda,California; Nicoya, Costa Rica; Okinawa, Japan; Sardinia, Italy; see Box 2-1). A team of experts thenused established methodologies to try to determine why people had suchremarkable longevity in these areas, which were dubbed “bluezones.” The intent, Buettner explained, was to identify lessons orprinciples that could be applied to build healthier communities and to helppeople live longer and better lives. In describing the five blue zones, Buettnershared the stories of several individuals, each close to or more than 100 yearsof age. He showed photos of them swimming, surfboarding, lifting weights,working, and volunteering in their community. Health information is boring, hesaid, even in the cases of the best research and data. Using a human story topresent health information increases audience engagement.
BOX 2-1
The Blue Zones. Ikaria, Greece The Greek Island of Ikaria has the greatestadherence to the Mediterranean diet in the world. The people live about 7years longer than Americans do. A survey by the University of Athens of all674 people over age 70 on (more...)
POWER 9® PRINCIPLES
In meeting numerous centenarians, Buettner realized that in no case did theyreach middle age and then decide to pursue longevity through a change indiet, taking up exercise, or finding some nutritional supplement. Thelongevity occurred because they were in the right environment—anenvironment that fostered a lifestyle of longevity. Regardless of location,the same nine lifestyle characteristics were identified across all five bluezone environments, which Buettner termed the “Power9®” principles. Activity, outlook, and diet arekey factors, and the foundation underlying behaviors is how people in bluezones connect with others (see Figure2-1).
FIGURE 2-1
Power 9® principles. Shared traits of thelongest-lived people from the five blue zones around theworld. SOURCE: Buettner presentation, July 30, 2104. Used withpermission.
Activity
Move Naturally The world's longest-livedpeople do not “exercise.” In blue zones,Buettner's team observed that people were nudged intomoving about every 20 minutes. For example, they were gardening,they kneaded their own bread, and they used hand-operated tools;their houses were not full of conveniences. When they did go out(e.g., to school, work, a friend's house, a restaurant,or to socialize), it was almost always on foot. Movement isengineered into their daily lives.
Outlook
Down Shift Stress is part of the human condition,Buettner said, and people in blue zones suffer the same stressesthat others do. However, the people living in blue zones havedaily rituals that reduce stress and reverse the inflammationassociated with stress. Rituals varied and included activitiessuch as prayer, ancestor veneration, napping, and happyhour.
Purpose In the blue zones, people have vocabularyfor purpose. Buettner described a recent study from Canada thatfollowed 6,000 people for 14 years and found that those peoplewho could articulate their sense of purpose had a 15 percentlower risk of dying. Another study, this one from the NationalInstitute on Aging, found that people who could articulate theirsense of purpose were living up to 7 years longer.
Diet
Wine at 5 Except for the Adventists, people in bluezones consumed moderate amounts of alcohol (most commonly twoglasses per day, but as much as four glasses per day).
Plant Slant A meta-analysis by Buettner of 154dietary surveys in all five blue zones found that 95 percent of100-year-olds ate plant-based diets, including plenty of beans.Beans are inexpensive, full of fiber and protein, andnutritionally rich, Buettner said. The 100-year-olds also eat alot of carbohydrates, but in the form of whole grains andsourdough breads rather than in breads leavened with yeast.
80 Percent Rule The longest-lived people havestrategies to keep themselves from overeating, Buettner said(such as the Confucian mantra some Okinawans use to stop eatingwhen they feel 80 percent full). There is clinical evidence thatstrategies such as stopping to say a prayer before meals, eatingslowly so that the full feeling can reach the brain, not havingtelevisions in kitchens, or eating with family lead to adecrease in food intake. In all five blue zones, people eat alarge breakfast and a smaller lunch, and dinner is the smallestmeal of the day.
Connections
Loved Ones First Centenarians spend a lot of timeand effort working on their relationships with their spouses andchildren. Children are likely to keep their aging parents nearbyand to consider them to be fonts of wisdom that will favor theirown survival.
Belong People in blue zones tend to belong to afaith-based community. Individuals of faith who regularly attenda faith-based service live 4 to 14 years longer than theircounterparts who do not, Buettner said.
Right Tribe Health behaviors are contagious,Buettner said. Deleterious behaviors (e.g., obesity, smoking,excessive drinking, loneliness, unhappiness) are alsocontagious. They world's longest-lived people“curate” social circles around themselves thatsupport healthy behaviors.
PRINCIPLES INTO ACTION: LIFE RADIUS
Americans spend more than $100 billion annually on diets, exercise programsand health club memberships, and nutritional supplements, Buettner said. Andwhile proper nutrition and exercise are good, this approach leads toshort-term successes and long-term failures. Interventions need to lastdecades or a lifetime to affect life expectancy and lower rates of chronicdisease, he said. Within 3 months of starting a diet, about 10 percent ofpeople will quit. Within 7 months only about 10 percent will remain on thediet, and by 2 years less than 5 percent will still be adhering to the diet.Exercise programs show a similar pattern, Buettner said. Many people startexercise programs after the end-of-year holidays and have quit by autumn.Adherence to daily medication regimens also drops off over time.
With additional funding from National Geographic, Buettnerset out to identify populations that were unhealthy but were able to improvetheir health and to determine what led to lasting improvement. In general,public health initiatives for non-infectious diseases have not beensuccessful, he said. Tens of millions of dollars have been spent on majorinitiatives (e.g., for heart disease prevention), and while there issometimes initial success in changing health behaviors, once the spotlightis off and the health researchers and media are gone, people revert to theirbaseline behaviors. One successful example Buettner did identify took placein North Karelia in Eastern Finland. In 1972 this region had the highestrate of cardiovascular disease in the world. A team led by Pekka Puskareduced the incidence of cardiovascular disease by 80 percent over 30 yearsand reduced the incidence of cancer by more than 60 percent. Puska'sapproach, Buettner explained, focused not on the individual but on theenvironment and the systems around the individual.
The Life Radius Approach to Optimizing the Living Environment
With funding from AARP, Buettner assembled a team of experts to considerhow to optimize what he dubbed the liferadius—the environment where people spend about 80percent of their lives (see Figure2-2). The best investment for optimizing the environment ispolicy, he said. For example, are fruits and vegetables affordable andaccessible, or are fast food and snacks cheapest and most accessible? Doordinances promote sprawl, or are there incentives for creating livablespaces? Is smoking widely permitted, or more difficult to do? (Forinstance, consider the difference between West Virginia, where smokingrates are as high as 35 percent, and San Luis Obispo, California, wheresmoking rates are less than 10 percent.)
FIGURE 2-2
Life radius. Optimizing the environment where people spend 80percent of their time. SOURCE: Buettner presentation, July 30, 2104. Used withpermission.
Another key factor is the built environment. By making the active optionthe easy and safe option, the activity level of an entire population canbe raised by 30 percent, Buettner said. People increase activity withoutgym memberships or exercise classes by, for example, walking or bikingto school, work, or shopping. Social networks are also important in thelife radius, strategically bringing together people who are ready tochange their habits and setting up a network to spread the lifestyle.There is also a huge opportunity to affect health through buildingdesign, Buettner said. The team identified 120 evidence-based ways thatschools, restaurants, grocery stores, workplaces, and other buildingscan be set up to nudge people to move more, eat less, eat better,socialize more, smoke less, and reduce stress. Finally, one factor thatis unique to the life radius approach is a focus on purpose. Buettnerdescribed workshops on purpose and initiatives to connect people tovolunteering, noting that volunteers have lower rates of cardiovasculardisease and lower health care costs.
12 Pillars
Taking the life radius approach forward, Buettner and his team focuson 12 “pillars.” The first three pillars are areas inwhich city governments can make a difference: the built environment,food policy, and tobacco policy. The approach is to start with aconversation, gradually introduce best practices, and ultimately getlocal leaders to choose 10 priorities and coach them to fruition.This is the best investment and has the biggest impact for thepopulation, Buettner said.
The next six pillars are the places where people spend their day:employers, schools, restaurants, grocery stores, faithorganizations, and home. The team developed checklists ofrevenue-neutral ways that these environments can be optimized forhealth, and it offers blue zone certification for those thatimplement a certain number of changes. The last three pillars areprograms for creating new social networks, getting people involvedin volunteering, and helping them define a sense of purpose.
Case Example: Albert Lea, Minnesota
Albert Lea, Minnesota, was selected from a handful of potential sites forthe pilot Blue Zones project. Buettner stressed the importance of havingcommunity and leadership buy-in and commitment as well as the need to“listen, not pontificate.” Albert Lea was a beautifulcity, but no one could walk anywhere. By connecting sidewalks, peoplecould walk downtown for dinner or to church or schools. Older people didnot have to walk through fields or cut across dangerous traffic. AlbertLea originally wanted to widen its main street and raise the speedlimit, which, Buettner said, creates stress, danger, noise pollution,and air pollution. Over a series of long conversations, the city agreedto instead put a trail around the lake at the end of the main street.That trail is now busy all of the time with people being active becauseit is easy, accessible, and pretty, Buettner said. A vast section of theparkland was simply open lawn. The team convinced the city to put in sixcommunity gardens, which Buettner said filled up instantly; a seventhgarden was added the second year. The gardens are not only a good placefor regular, low-intensity physical activity, he said, but a place forpeople to connect.
Grocery store and restaurant pledges were developed to help change theway people eat. For example, at a blue zone restaurant patrons have toask for bread, rather than having it brought to the table automatically.Sandwiches come with fruit, but diners can ask for fries instead.Buettner also described the impact of changing the adjectives on menus.For example, no one wants to order the “healthy choicesalad,” but call it the “Italian primavera salad”and sales increase. Restaurants also let diners know that they can ordersplit plates or take leftovers home. The big grocery chain agreed to taglongevity foods and created a blue zone checkout aisle with healthysnacks in the racks. Schools agreed to implement a policy of no eatingin hallways or classrooms. A blue zone club was also established, andabout 25 percent of the population signed a personal pledge to takeaction toward achieving a set of personal health and lifestylegoals.
In association with the University of Minnesota, Buettner developed the“vitality compass,” a free tool that lets people calculatetheir overall life expectancy and three other broad metrics.2 A total of 33 metricsare captured (e.g., what people eat, how often they attend a house ofworship, and their body mass index [BMI]). Completing the assessment atbaseline and again sometime later after implementing changes can providea fairly good measurement of impact. Some residents agreed to let bluezone team members come into their homes and optimize theirkitchens—for example, with smaller plates, planting gardens, etc.About 1,100 people joined community walking groups (“walkingMoai”3), 60 percent of which are still together 5 yearslater. Residents also attended a purpose-defining class and were quicklymatched with volunteer organizations to provide them with an outlet fortheir newly articulated purpose.
After the first year of the pilot project in Albert Lea, with 3,400participants (24 percent of the population), entering theparticipants' information in the vitality compass programsuggested an average life expectancy gain of 3.2 years due to changes intheir life habits. Participants also self-reported a collective weightloss of 7,280 pounds. The city of Albert Lea independently reported a 40percent drop in health care costs for city workers. Buettner noted thatsome of these figures briefly caught national media attention, but theunderlying question is what were the permanent or semi-permanent ways inwhich the environment or ecosystem was changed.
Creating More Blue Zones
After the Albert Lea pilot project, the Blue Zones project teamed up withHealthways and issued nationwide request for proposals for the next bluezone city. From the 55 cities that applied, the Los Angeles Beach Cities(Hermosa, Redondo, and Manhattan Beach) were selected. After 3 years,the measurement of 80 different facets of well-being (physical andpsychological) by Gallup–Healthways showed a 14 percent drop inobesity (compared to a 3 percent drop in obesity across California), a30 percent drop in smoking, and better self-reported eating habits andincreased physical activity.
Buettner said that these results caught the attention of Blue Cross/BlueShield of Iowa and of the governor of Iowa, Terry Branstad, who invitedthe Blue Zones project to conduct a publicly supported, privately fundedstate-wide blue zones initiative. Iowa is a state with a huge porkindustry, Buettner pointed out. Instead of trying to address the entirestate of 3.2 million people and 995 cities at once, the Blue Zonesproject set up demonstration cities. Ninety-three cities“auditioned,” and the 10 cities that were most ready forchange were selected. Impressive drops in obesity rates and increasedhealth care costs savings are already being observed, and BlueCross/Blue Shield of Iowa actuaries are calculating a health caresavings over a 10-year period of $5 billion due to the establishment ofblue zones. New blue zone projects are now starting up in Fort Worth,Texas, and Kauai, Hawaii.
GOING TO SCALE
Buettner closed his presentation by sharing some lessons learned from workingwith 20 cities through six iterations of the project. Scale is the hardestaspect of the project, Buettner said. The first lesson in achieving scale isto start with “ready” communities. Unlike public health, whereinterventions are targeted at the most at-risk populations, preventiontargets the people who are most ready for it. It takes some time to findthat readiness, he said, and you have to say no to some communities. Investin rigorous measurement. “If you can't measure it, youcan't manage it,” he said, and data are needed to back up theapproach. Orchestrate “the perfect storm,” he recommended,engaging the schools, restaurants, grocery stores, city council, and themedia, so that everyone is hearing about blue zones everywhere they go.Finally, the process takes time. A workplace may be able to instituteeffective interventions in 1 year, but communities really need 3 to 5 years,often longer, in part because policy change can be a slow process.
There is no downside to any of the interventions, Buettner concluded. Hesuggested thinking about programs as an operating system, and striving tomake permanent or semi-permanent changes to the system.
DISCUSSION
The open discussion that followed expanded on the concepts of readiness andscale. Buettner emphasized the value of a few successful demonstrationprojects in creating broad interest. Engaging everyone at once is generallynot successful, he said. When working with communities, one should try toidentify those employers who are most committed, and who are willing tocommit some of the budget from human resources, marketing, their foundation,or other departments and orchestrate that perfect storm. He added that dataon workplaces suggest that the main determinant of whether or not anemployee likes his or her job is whether he or she has a best friend atwork. Businesses have an enormous opportunity to connect peoplestrategically so that their relationships transcend the commercial orbusiness relationships. Set up those networks internally, make small changesto the policies and the built environment, and measure rigorously. Once youhave shown what works, distill that into a scalable model for othercompanies, starting with the companies that are most ready and mostcommitted, he said.
A participant expressed concern that some of the most at-risk communities maynever be as “ready” as Albert Lea and that not including themmight exacerbate some of the disparities further. Buettner clarified thatblue zones tries to intervene at the whole city level, adding that 15percent of the population of Albert Lea is Hispanic migrant workers who arevery poor. Although the Blue Zones project may not necessarily be working inthe poorest neighborhoods, the policy changes made (e.g., de-normalizingtobacco, making healthy foods more accessible and affordable) should benefitall of the communities in a city. Another participant suggested that some ofthe concepts about readiness are related to equity. How do we create morereadiness in communities so that they are more prepared to change? Buettnerclarified further that the Blue Zones project does not necessarily assessindividual readiness as much as leadership readiness and whether the privateand public sectors are open to innovation. Sign-on from the leadershipcomponents usually reflects the support of a larger population, he said.
A participant observed that for the original blue zones there was the senseof population hom*ogeneity and a common culture and wondered whether morediversity within a city affects the outcomes. Buettner responded that it iseasier if the population is more hom*ogeneous, has a strong sense of civicunity and pride, and speaks a common language. However, the Los AngelesBeach Cities are very diverse and the initiatives have been verysuccessful.
- 1
See http://www
.bluezones.com (accessed December 12,2014). - 2
See http://apps
.bluezones.com/vitality (accessed December12, 2014). - 3
Moai, pronounced “Mo Eye,” is an Okinawan term that roughlymeans “meeting for a common purpose.” For more informationabout walking Moais, see https://www
.bluezonesproject .com/moai_events (accessedDecember 12, 2014).
